Periodic catatonia is an important diagnostic entity, although not diagnosed.1 In this letter we discuss a patient who presented with mutism and other catatonic signs. Mr. A, age 62, is a 3-pack-per-day smoker and has a medical history of chronic obstructive pulmonary disease, coronary artery disease, prostate cancer, hypercholesterolemia, hypertriglyceridemia, and gastroesophageal reflux disease. He was given diagnoses of major depressive disorder, schizoaffective disorder, adjustment disorder, posttraumatic stress disorder (PTSD), periods of selective aphasia, alcohol abuse, essential tremor, and possible catatonia. Mr. A has been treated in the Veterans Affairs system for >10 years. He has multiple inpatient admissions with mutism, auditory hallucinations, and paranoid delusions. He would improve with treatment and regain normal conversational speech.

He was being treated with divalproex extended release, 2,000 mg/d, and perphenazine, 2 mg/d. He requested to be hospitalized because he was “strung out and very depressed.” It also is notable that at the time he had tremors bilaterally. He was diagnosed with PTSD. Mr. A complained of tremor and perphenazine was lowered and discontinued. His verbal communication decreased, and instead he developed gestures to communicate with staff and other patients. He eventually became mute. He spent more time in bed, had decreased social interaction, and decreased food and water intake. The patient was rated on Bush-Francis Catatonia Rating Scale = 7 (mutism, bradykinesia, grimacing, and withdrawal) and the KANNER Catatonia Rating Scale (Katatonia Autism Neuropsychiatric Neuromovement Examination Rating Scale) part 1: 3 screening signs (mutism, refusal to eat and drink), part 2 score: 24 signs, and part 3: 3 signs (catalepsy, magnetism, and metronome test).2,3 The head CT was negative. A speech pathology consult revealed that the patient presented with fair cognitive abilities. He showed hesitations in verbal expression, which did not appear to be associated with anxiety, aphasia, apraxia, or akinetic mutism. Neuropsychological testing revealed initial encoding as the deficit in his learning and memory. Slowed processing speed may have contributed to difficulties with comprehension of longer and/or more complex verbal information.

Mr. A was restarted on perphenazine, 2 mg/d, and it was noted that he was more socially engaging and talking more within 1 week. He reported his mood as 10 on a zero to 10 scale with no anxiety and he felt that the medication was helping. When he was seen 2 months after discharge, his appearance was appropriate and he was cooperative. Mr. A also was alert and oriented to person and place. His speech was fluent, his mood was appropriate with full affect, and his thought process was logical. There was no obvious lethality, delusions, or hallucinations. He was living independently in the community. Bush-Francis Catatonia Rating Scale was 2, KANNER Catatonia Rating Scale on part 2 was 2 (stereotypy).

Mr. A exhibited an episodic psychotic disorder characterized by mutism and other catatonic signs. He did respond to perphenazine. He also did not respond to memantine or lorazepam.4

DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.